D027 Shadow Health Treatment Plan for Dr. Douglas: Phase 3 Guide
Patient Overview: Dr. Anita Douglas
Who is the patient?
Dr. Anita Douglas is a 72-year-old African American female who lives with her spouse. She is retired and formerly held the position of Veterinary Chief. Her age, ethnicity, and professional background provide important context for understanding her health and lifestyle, which influence both her current condition and treatment approach.
Presenting Complaints and Symptom History
What symptoms is the patient currently experiencing?
Dr. Douglas reports a fever lasting one day and nasal congestion for three days, accompanied by yellow-green nasal discharge. She also experiences a productive cough producing rust-colored sputum. She has localized pain in the right lower chest area that worsens with coughing or deep breaths. Additionally, she complains of fatigue and generalized muscle aches, suggesting systemic involvement of her illness.
Lifestyle and Activity Patterns
What is Dr. Douglas’s level of physical activity?
Her physical activity is light; she walks for about 10 minutes two to three times weekly. This limited exercise regimen may affect her cardiovascular health and potentially slow her recovery process.
What dietary habits does she follow?
Dr. Douglas maintains a lacto-ovo vegetarian diet, including dairy and eggs but excluding meat. This dietary pattern can influence her nutritional status and immune system, which are important factors in managing infections and overall health.
Vaccinations and Allergy Status
| Vaccination | Date Administered |
|---|---|
| Influenza | 3 months ago |
| Pneumococcal | 12 years ago |
Does Dr. Douglas have any known allergies?
She has no known drug allergies (NKDA) or food allergies (NKFA). This simplifies medication selection and reduces the risk of allergic complications during treatment.
Medical History and Current Medications
What are the significant medical conditions in Dr. Douglas’s history?
Dr. Douglas has chronic kidney disease stage 2 (CKD-2), diagnosed nine years ago, pulmonary hypertension (P-HTN), and hypertension (HTN), which has been managed for 14 years. These chronic conditions require careful medication adjustments and monitoring when treating acute illnesses such as pneumonia.
Which medications and supplements is she currently using?
| Medication/Supplement | Dose/Frequency | Purpose |
|---|---|---|
| Trandolapril/Verapamil | 2 mg / 180 mg daily | Blood pressure management |
| Chlorothiazide | 500 mg twice daily | Diuretic for hypertension |
| Aspirin | 325 mg as needed | Pain relief and anti-inflammatory |
| Calcium | 1200 mg daily | Bone health |
| Vitamin D | 15 mcg daily | Bone and immune support |
Does Dr. Douglas smoke or consume alcohol?
She is a non-smoker and drinks 1-2 glasses of wine per week. There is no reported use of illicit drugs.
Diagnosis
What is the confirmed diagnosis for Dr. Douglas?
Dr. Douglas has been diagnosed with Community-Acquired Pneumonia (CAP), a common respiratory infection often caused by bacterial or viral pathogens. Symptoms typically include fever, productive cough, and chest pain, all of which are present in her case.
Discharge Treatment Plan
What instructions have been provided for Dr. Douglas’s care post-discharge?
| Instruction | Details |
|---|---|
| Rest | Aim for 8 hours of sleep each night |
| Hydration | Increase fluid intake to 64 ounces daily |
| Antibiotic Therapy | Begin Amoxicillin/Clavulanate and Doxycycline |
| Medication Adjustment | Discontinue Aspirin |
| Pain and Fever Management | Use Tylenol (acetaminophen) as needed |
| Treatment Compliance | Complete the full course of antibiotics |
| Missed Dose Protocol | Take a missed dose as soon as remembered |
Prescription Details
| Medication | Dose/Instructions |
|---|---|
| Amoxicillin/Clavulanate | 500 mg/125 mg orally every 12 hours for 5 days (10 capsules). Take with water before or after meals; do not crush or chew. |
| Doxycycline | 100 mg orally every 12 hours for 5 days (10 capsules). Take on an empty stomach (1 hour before or 2 hours after food). Drink plenty of fluids to avoid throat irritation. |
Important Medication Precautions
What precautions should Dr. Douglas follow with her medications?
Dr. Douglas must space doses evenly every 12 hours, preferably morning and evening, to maintain therapeutic drug levels. It is vital to follow all medication instructions exactly. Should she experience allergic reactions—such as hives, rash, swelling, throat tightness, difficulty swallowing or breathing, or chest pain—she must immediately stop the medication and seek emergency care.
Follow-Up and Emergency Guidance
When should Dr. Douglas seek further medical assistance?
A follow-up appointment is scheduled one week after discharge to monitor her recovery. She should seek urgent medical evaluation if her symptoms worsen or if new symptoms develop. This could include visiting her primary care clinic or going to the emergency room after hours.
References
Centers for Disease Control and Prevention. (2023). Community-Acquired Pneumonia (CAP). Retrieved from https://www.cdc.gov/pneumonia/community-acquired.html
Musher, D. M., & Thorner, A. R. (2014). Community-acquired pneumonia. New England Journal of Medicine, 371(17), 1619–1628. https://doi.org/10.1056/NEJMra1312885
Smith, R. J., & Smith, T. L. (2021). Management of bacterial pneumonia in adults. American Family Physician, 104(10), 1055–1063.